MOA 1030 - Insurance

Clock Hours: 40

Delivery Mode
on-ground

Course Description:
This course is designed to introduce the student to the basics of medical insurance, including insurance terminology, private payers and government programs, and general insurance procedures and policies. The Insurance course presents an overview of major issues related to the design, function, management, regulation, and evaluation of health insurance and managed care plans. This course is composed of lecture and learning modules delivered in an open entry open exit format. The course provides a firm foundation in basic concepts pertaining to private and public-sector health insurance/benefit plans, both as provided by employers and government agencies such as Medicaid and Medicare. Key topics include population care management techniques, provider payment, organizational integration, quality and accountability, cost-containment, and public policy.

Student Learning Outcomes:
Upon completion of this content area, the student will be able to:

Describe the major issues related to the design, function, management, regulation, and evaluation of health insurance programs and managed care organizations, including HMOs.
Differentiate between private and public-sector programs.
1. Compare and contrast government and private insurance and HMO and PPO plans
2. Identify major types of commercial insurance
3. Identify the three government insurance plans.
Function as healthcare providers dealing with the following health insurance/ managed care issue areas:
1. Finance and organization
2. Network structure
3. Medical management
4. Quality monitoring and improvement
5. Special need populations
6. Mental health
7. Pharmacy benefits
Print and mail insurance forms.
File electronic claims.
Describe the claims process.
Determine primary insurance.
Explain basic insurance information and benefits, eligibility, preauthorization procedures, precertification procedures, predetermination procedures, filing deadlines, and third-party liability common to all insurance carriers such as:
1. Medicare - Part A & B
2. Medicaid
3. The Blue Plans/Private Insurance/Managed
4. Workers’ Compensation
5. TRICARE/CHAMPVA
6. Disability
Become familiar with managed care contracts between physicians and insurance carriers that may affect insurance reimbursement.
Transfer simple, moderate, and complex case histories onto insurance forms.
Apply legal considerations for sharing and protection of the patient’s health information/medical record.
Explain claim follow-up and payment processing:
1. Delinquent payments
2. Rebilling
3. Appeals
4. Understands claims review
5. Billing secondary insurance
6. The remittance advice
Calculate patient balances.
Verify coverage benefits, copay, insurance card (primary, secondary, tertiary), basic coding, birthday rule, and policyholder.
Follow the Center for Medicare/Medicaid Services (CMS) guidelines.
1. Know how to report Medicare/Medicaid fraud